Medicine and Health Sciences Commons^™

Laryngeal Mask Airway Insertion Anaesthesia And Insertion Techniques, Abdul Monem, Fauzia A. Khan

Department of Anaesthesia

Laryngeal Mask Airway has gained wide acceptance for routine airway management, difficult airway and in emergency situations. The classical method of insertion was recommended by Dr Brain. Over the years various induction and insertion techniques have been described with variable results. Combination of induction agents with narcotics, with or without small dose muscle relaxants has been found to be very effective. There is less also lesser incidence of mucosal trauma with partially inflated cuff. Insertion with cuff facing laterally or backwards and rotating it forwards into position has also been described. A review of various options and their advantages and …

Epidural Anaesthesia During Labour For A Patient With Congenital Complete Heart Block: A Case Report, Abdul Monem, Ursula Chohan, Mohammed Ali

Department of Anaesthesia

We report labour pain management in a full-term pregnant patient with Congenital Complete Heart Block. She delivered uneventfully under routine monitoring with facilities for pacing at hand. She previously had an uneventful normal delivery and a D&E, both outside our hospital. Only findings were a low heart rate of 45-50 beats per minute. She never had syncopal attacks. She had a good effort tolerance on ETT. Her ejection fraction was 60% on Echocardiogram. She was given a single shot low dose spinal with fentanyl followed by epidural insertion. She successfully delivered through mid-cavity forceps in about 2.5 hours. The only …

Comparison Of Two Sedation Techniques In Patients Undergoing Surgical Procedures Under Regional Anaesthesia, Aliya Ahmed, Fauzia Anis Khan, Aziza Hussain

Department of Anaesthesia

Objective: Intraoperative comfort and patient satisfaction during surgical procedures under regional anaesthesia can be improved with the use of supplemental intravenous sedation. The authors conducted a study to compare two sedation techniques for surgical procedures performed under regional anaesthesia, i.e., midazolam and pethidine combination compared with midazolam and tramadol combination.Methods: Forty adult American Society of Anaesthesiologists (ASA) grade 1-111 patients, aged between 40-65 years undergoing surgery under regional anaesthesia (sub-arachnoid block) were included. The patients were randomly divided into two groups. All patients received standardized premedication, intraoperative monitoring and oxygen therapy. Group A patients received midazolam 0.03 mg/kg followed by …

Audit Of An Acute Pain Service In A Tertiary Care Hospital In A Developing Country, Muhammad Qamarul Hoda, Mohammad Hamid, Fauzia Anis Khan

Department of Anaesthesia

The first anaesthesia based acute pain service (APS) was introduced in Pakistan at the Aga Khan University Hospital in July 2001, with the aim of patient safety and satisfaction. The American Society of Anesthesiologist task force guidelines were used for the introduction of APS. APS has managed 6810 patients during four and half years period. Common analgesic techniques used, were intravenous infusion (50%), patient controlled intravenous analgesia (18%) and epidural infusions (30%). Common reported side effects were nausea and vomiting with intravenous infusion (10%) and PCIA (10%) while motor block was noticed with epidural infusion (29%). This article aims to …

Arterial To End-Tidal Carbon Dioxide Difference In Neurosurgical Patients Undergoing Craniotomy: A Review Of Practice, Fauzia Anis Khan, Mueenullah Khan, Shemila Abbasi

Department of Anaesthesia

Objective: To see if PETCO2 reflects PaCO2 with acceptable accuracy.Methods: In this audit the.anaesthetic chart of fifty consecutive patients, age 12 years and above undergoing craniotomy for intracranial pathology, were reviewed.Results: The difference between end tidal carbon dioxide (ETCO2) value corresponding to the time of taking the arterial sample and the PaCO2 was calculated. The mean end tidal CO2 was 29.3 +/- 2.8 and the mean PaCO2 was 32.63 +/- 4.5. The mean difference between the two values was calculated as 4.09 +/- 3.0. The regression coefficient was 0.496, which showed a moderate association. A wide variability was observed in …

Role Of Stellate Ganglion Block In Post Cabg Sympathetically Mediated Chest Pain, Mueen Ullah Khan, Imtiaz Ahmed

Department of Anaesthesia

Acute chest pain is a common presentation in emergency. After clinical assessment undiagnosed chest pain can become a difficult problem. Sympathetically mediated chest pain is a rare presentation, as it is similar to that of secondary hyperalgesia in the intact skin surrounding an injury site. We are reporting a case of a 62 years old man who presented with atypical chest pain four months after coronary artery bypass grafting (CABG). On investigation no new change was noticed than previous evaluation. On chronic pain assessment he was having hyperalgesia to light touch in addition to the spontaneous chest pain. He was …

Severe Anaphylactic Reaction At Induction Of Anaesthesia, Aliya Ahmed, Anand Kumar

Department of Anaesthesia

Anaphylaxis is an IgE mediated severe allergic reaction causing release of vasoactive substances from mast cells and basophils after re-exposure to an antigen. Signs and symptoms include flushing, urticaria, hypotension, tachycardia, bronchospasm, cardio-respiratory arrest etc. It can occur at induction of anaesthesia when multiple drugs are being administered, but prompt diagnosis with correct management is the key to a successful outcome. This case report describes a patient who developed severe bronchospasm with difficulty in inflating the lungs and dropping oxygen saturations, alongwith hypotension, tachycardia and widespread flushing, at induction of anaesthesia for elective breast surgery. She was promptly managed and …

Adequacy Of Postoperative Pain Relief After Discharge, Samina Ismail, Aziza M. Hussain

Department of Anaesthesia

Day care surgery has shown a remarkable development over the last two decades, comprising approximately 60-70% of all surgical procedures. Therefore major proportions of surgical patients are recovering at home and have little or no assessment of the adequacy of their pain relief. The aim of our audit was to compare suggested postoperative pain indicators with targets for best practice. This audit was done at the Aga Khan University Hospital day care unit for a period of three months. On the day of surgery patients having the contact numbers were informed about the telephone call 24 hrs after the surgery …

Intraoperative Analgesia For Day-Care Surgery: Practice Trends, Aliya Ahmed, Shemila Abbasi, Chandar Prakash, Subhash Chandar

Department of Anaesthesia

Our objective was to determine the trends of providing intraoperative analgesia for day-care surgery among the various anaesthesiologists at our university hospital. All patients having surgical procedures under general anaesthesia in the Surgical Day Care Unit (SDC) of the Hospital were included. The study was done over two months and 142 patients were enrolled during the study period. Of these 45% received pethidine for intraoperative analgesia, 24% pethidine and ketorolac, 6% pethidine and paracetamol suppositories, 18% received fentanyl, 2% tramadol and 5% received other analgesic combinations. Of the 22% patients who received pethidine intraoperatively needed rescue analgesia in recovery room, …

Customer Focused Incident Monitoring In Anaesthesia, F A. Khan, S Khimani

Department of Anaesthesia

The database of incident forms relating to anaesthesia services in an institutional risk management programme were reviewed for 2003-2005, the aim being to identify any recurring patterns. Incidents were prospectively categorised as relating to attitude/behaviour, communication breakdown, delay in service, or were related to care, cost, environment, equipment, security, administrative process, quality of service or miscellaneous. The total number of anaesthesia-related incidents reported during the period was 287, which related to 0.44% of the total number of anaesthetics administered during the time period. In all, 170 incidents were reported by the department, 96 by internal customers and 21 by external …

Postoperative Sore Throat After Elective Surgical Procedures, Aliya Ahmed, Shemaila Abbasi, Hasham Bin Ghafoor, Muhammad Ishaq

Department of Anaesthesia

Postoperative sore throat is a common complication of anaesthesia and can lead to dissatisfaction after surgery. Many factors can contribute to postoperative sore throat and the incidence varies with the method of airway management Methods: In this prospective observational study elective gynaecological and general surgical patients were interviewed 24 hours postoperatively to determine the presence of sore throat. Information collected included demographic data, surgical procedure, duration of surgery, airway device used and position of patient during surgery. This study was done over a period of 3 months. Results: 312 patients were interviewed. 81(26%) patients suffered with sore throat postoperatively. 28% …

Perioperative Management Of Pheochromocytoma: Anaesthetic Implications, Aliya Ahmed

Department of Anaesthesia

Pheochromocytoma is a catecholamine producing tumour that can cause severe hypertension and other systemic disturbances. The perioperative management of pheochromocytoma remains a complicated anaesthesia challenge requiring intensive preoperative preparation and vigilant intraoperative and postoperative care. In this article the perioperative management of pheochromocytoma is reviewed by first summarizing its pathophysiology, clinical aspects and diagnosis, then highlighting the preoperative optimization of the patient and finally describing the intraoperative and postoperative anaesthetic management in the light of the current information.

Anesthetic Deaths In A Developing Country, Mueenullah Khan, Fauzia A. Khan

Department of Anaesthesia

It is important to ascertain the contribution of anesthesia to perioperative mortality in order to enable improvement in the safety and quality of care. Scanty literature regarding anesthetic mortality from developing countries is available. We present data regarding anesthesia related mortality in a university hospital in a developing country. We reviewed all patient deaths occurring between 1992-2003 occurring within 24 hours of anesthesia, as part of departmental quality assurance activity. The aim of study was to identify any contributing factors associated with mortality, and to compare our data with similar studies from developed and developing countries. 111,289 cases were handled …

Tramadol Versus Nalbuphine In Total Intravenous Anaesthesia For Dilatation And Evacuation, Khalid Maudood Siddiqui, Ursula Chohan

Department of Anaesthesia

Objective: To compare the results of Tramadol with Nalbuphine for dilatation and evacuation with total intravenous anaesthesia technique.Methods: A total of 70 patients (35 in each group) were included in this prospective, double blind randomized study. Intravenous tramadol 1.5 mg/kg and nalbuphine 0.1 mg/kg were compared in total intravenous anaesthesia (TIVA) using a propofol infusion in patients undergoing dilatation and evacuation (D and E). Changes in haemodynamic variables greater than 20% from the base line values were noted.Results: There was no difference found in haemodynamic parameters. There was statistically significant difference found (p < 0.05) in postoperative recovery between the two groups.CONCLUSION: Quality of analgesia was better in nalbuphine group but both drugs provide suitable analgesic supplementation to TIVA.

Implementation Of An Antibiotic Nomogram Improves Postoperative Antibiotic Utilization And Safety In Patients Undergoing Coronary Artery Bypass Grafting, Thomas J. Papadimos, Jennifer L. Grabarczyk, Daniel F. Grum, James P. Hofmann, Alan P. Marco, Sadik A. Khuder

Anesthesiology Faculty Publications

Background

Routine, initial, empiric vancomycin dosing by clinicians in postoperative coronary artery bypass grafting (CABG) patients was identified as a potential patient safety issue in the Cardiovascular Intensive Care Unit (CVICU) because the rate of postoperative acute renal insufficiency (ARI) and average patient Body Mass Index (BMI) > 35 kg/m2 were significantly higher in our institution than those of the Society of Thoracic Surgeons (STS) database. A vancomycin dosing nomogram was derived from the local patient population in the attempt to improve patient safety by convincing clinicians to use an evidence-based approach to vancomycin prescription.

Methods

We analyzed two different treatment …

Pulmonary Artery Catheter Knotting In A Coronary Artery Bypass Surgery Patient, Mohammad Irfan Akhtar, Mohammad Hamid, Fazal Hameed Khan, Hamid Iqil Naqvi, Amar Gangwani

Department of Anaesthesia

A fifty seven years old female patient came to operating room for coronary artery bypass grafting (CABG) surgery. After induction, invasive monitoring lines were placed. Pulmonary artery catheter (PAC) floated after three attempts and it was wedged at 60cm. Intra operative course was smooth and patient transferred to cardiac intensive care unit (CICU). First chest X-ray revealed PAC knotting in the right ventricle. Vascular surgeon was involved and he removed it through right internal jugular vein under fluoroscopic guidance. Pulmonary arterial catheterization is an invasive procedure. Knotting usually occurs due to excessive advancement of the pulmonary artery catheter beyond the …

Impact Of Antibiotic Restriction On Broad Spectrum Antibiotic Usage In The Icu Of A Developing Country, Shahla Siddiqui, Kashif Hussein, Roshan Manasia, Aijaz Samad, Nawal Salahuddin, Afia Zafar, M. Qamarul Hoda

Department of Anaesthesia

Objective: To reduce rates of nosocomial pneumonia and cost of antibiotic therapy.
Methods: By means of a policy implementation the following broad spectrum antibiotics were restricted to usage in the ICU for 72 hours: Cefepime, Meropenem, Imipenem, Tazocin, Polymixin B and Vancomycin, after an institutional based pharmacy and therapeutic committee approval. The ICU pharmacist would alert the ICU residents or consultants after 48 hours of the computer based antibiotic entry that the order would expire within hours. Telephone approval was obtained followed by a formal consultation if deemed necessary by the ID specialist or primary team. Antibiotic usage was …

Anaesthesia For Interventional Neuroradiology, Aliya Ahmed

Department of Anaesthesia

There have been rapid and significant advances in diagnostic and interventional radiology, including interventional neuroradiology, in recent years. Many intracranial vascular pathologies are being successfully managed by endovascular interventional neuroradiology techniques. These techniques include procedures like embolization of vascular tumours and arterio-venous malformations, coiling of cerebral aneurysms. etc. The support of anaesthesia team is requested for these therapeutic endovascular neuroradiological procedures. The main aims of the anaesthesiologist during any interventional neuroradiology procedure are provision of a physiologically stable and immobile patient, alteration of arterial blood pressure as necessary, and appropriate and timely management of complications. Provision of anaesthesia in remote …

Premedication In Surgical Day Care Patients, Saminal Ismail, Fauzia A. Khan, Aliya Ahmed, Khalid A. Shah

Department of Anaesthesia

The purpose of this audit was to find out the efficiency
of our system in providing premedication to surgical day
care patients. This audit was conducted in the Surgical Day
Care (SDC) Unit of a University Hospital. All patients
anaesthetised in the SDC unit on day care basis were included
in this audit. Nursing notes and preoperative orders of all
patients to be anaesthetised were checked to see whether
premedication was given or not and was the timing according
to the orders written. The result showed that out of 205
patients scheduled, twenty (9.7%) patients did not receive
premedication. Only …

Mid Aortic Syndrome Correction: Anaesthetic Considerations And Management, Mohammad Irfan Akhtar, Mohammad Hamid, Muneer Amanullah, Mubashar Khan, Shahabuddin, Mansoor Ahmed Khan

Department of Anaesthesia

A twelve years old female patient presented with headache off and on and disparity between upper and lower limb pressures. On the basis of history, physical examination and magnetic resonance angiography, the patient was diagnosed as mid aortic syndrome and planned for elective aorto aortic bypass graft surgery through left thoracotomy. Double lumen endotracheal tube was placed for lung isolation and episodes of hypertension during proximal and distal cross clamp were controlled with sodium nitropruside infusion (SNP). Extra pleural catheter was put in at the end of surgery before chest wall closure for postoperative pain control. Both upper and lower …

Haemodynamic Response To Tracheal Intubation Via Intubating Laryngeal Mask Airway Versus Direct Laryngoscopic Tracheal Intubation, Naveed Tahir Siddiqui, Fazal Hameed Khan

Department of Anaesthesia

Objective: To compare the haemodynamic response to tracheal intubation using either direct larygoscopy or Intubating Laryngeal Mask Airway.
Methods: This was a prospective randomized controlled trial. One hundred adult ASA-I and ASA - II patients coming to the Anaesthesia Department of Aga Khan University Hospital were randomly divided into two groups. In group- I endotracheal intubation was done with the help of Macintosh laryngoscope while in group-II patients were intubated with the help of the Intubating Laryngeal Mask Airway. Systolic, diastolic, mean arterial blood pressure and heart rate were recorded at baseline, at laryngoscopy and at 1 minute interval for …

Emergency Airway Management Of A Patient With Mediastinal Mass, Anwar Ul Huda, Khalid Maudood Siddiqui, Fazal Hameed Khan

Department of Anaesthesia

Appropriate airway management is an essential part of anaesthesiologist's role. Extrinsic airway compression by rapidly growing mediastinal masses represents a therapeutic challenge to anaesthesiologists. We report a case of successful airway management in a patient with obstructed airway. The patient was a middle aged female who presented with severe respiratory distress secondary to a huge mediastinal mass. CT scan showed widened superior mediastinum with circumferential narrowing of trachea and left main bronchus. Her condition continued to deteriorate during her hospital admission, so emergency intubation and tracheostomy was planned. She was intubated with the help of a bougie using size 6 …

Attenuation Of Hypotension Using Phenylephrine During Induction Of Anaesthesia With Propofol, Muhammad Imran, Fazal Hameed Khan, Mansoor Ahmed Khan

Department of Anaesthesia

Objective: To observe if phenylephrine mixed with propofol can attenuate hypotensive effects of propofol during induction of anaesthesia.
Methods: A total number of 135 adult ASA-I and ASA-II patients were divided into three groups. (Group A, B and C). All patients were induced with propofol 2.5 mg per kg. In Group A (control group) patients received propofol mixed with 2cc of 0.9% normal saline. Group B (study group) patients received propofol mixed with 2cc of a solution containing phenylephrine 25µg/cc (total 50µg); Group C (study group) patients received propofol mixed with 2cc of a solution containing phenylephrine 50µg/cc …

Anesthesia Clinical Performance Outcomes: Does Teaching Methodology Make A Difference?, Nina E. Mclain

Theses and Dissertations

Researchers have studied memory recall of crisis-oriented or emotional events in non-educational settings. However, within the health care field, there has been a limited study of the the concept of recall of crisis oriented or emotional events in& health care education. Crisis-oriented events such as natural disasters, acts of bioterroism, and industrial accidents, have been reported to impact memory. Patient safety is a primary focus in anesthesia education, appropriate crisis management is imperative to quality anesthesia care. Due to the critical nature of anesthesia delivery, there is a strong, constant need to develop methods that will enhance, support, and improve …

The Perioperative Librarian: Luxury Or Necessity?, Denise Hersey, Viji Kurup

Denise Hersey